Terminology. ECA Study. Studies on Co morbidity Most widely cited studies: Dual dx MICA CAMI Co Morbid Disorders Co Occurring Disorders

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1 Psychiatric Co Morbidities Jeffrey Selzer, MD, FASAM Associate Professor of Psychiatry Hofstra North Shore LIJ School of Medicine Albert Einstein College of Medicine Medical Director, NYS Committee for Physician Health Region 1 Director, ASAM Name Jeffrey Selzer ASAM Disclosure of Relevant Financial Relationships Content of Activity: ASAM Review Course 2014 Commercial Interests Relevant Financial Relationships: What Was Received Relevant Financial Relationships: For What Role No Relevant Financial Relationships with Any Commercial Interests x Topic Areas Terminology Epidemiology Substance induced mental disorders Treatment of specific co occurring disorders Nicotine use disorders and mental illness General treatment recommendations Terminology Dual dx MICA CAMI Co Morbid Disorders Co Occurring Disorders Studies on Co morbidity Most widely cited studies: Epidemiologic Catchment Area (ECA) study National Comorbidity Survey (NCS) National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) ECA Study Epidemiologic Catchment Area (ECA) Study 20,291 interviews at 5 sites Data Collected DSM III Diagnoses Regier, DA, et al. (1990). Comorbidity of Mental Disorders with Alcohol and other Drug Abuse: Results From the Epidemiologic Catchment Area (ECA) Study, JAMA, 264,

2 ECA DSM III Diagnoses (rates per 100 people) Any Alcohol, Drug or Mental Health Disorder 1 Month Lifetime Any Mental Alcohol Dependence Drug Dependence Regier, et al. (1990) Specific Mental Disorders and Substance Use Disorder Risk All Mood disorders 32% (O.R. = 2.6) Bipolar I disorder 61% (O.R. = 7.9) All Anxiety disorders 23.7% (O.R. = 1.7) Schizophrenia 47 % (O.R. = 4.6) Personality disorders: Antisocial personality disorder 83.6 %, Borderline personality disorder 50% (of those receiving treatment so may not reflect community sample) Regier, et al. (1990) Lifetime Prevalence and Odds Ratios ECA Study NCS National Comorbidity Survey 8,098 interviews across the country Data collected DSM III R Diagnoses Merikangas, KR, et al. (1998). Comorbidity of substance use disorders with mood and anxiety disorders: Results o the international consortium in psychiatric epidemiology. Addictive Behavior, 23, NCS DSM III Diagnoses NCS DSM III Diagnoses % OR Merikangas, KR, et al. (1998) Number of mental disorders Merikangas, KR, et al. (1998) 2

3 Nunes and Weiss, The ASAM Principles of Addiction Medicine 5 th Ed., 2014 National Survey on Drug Use and Health, 5/2011 COD in Treatment Populations Substance Induced Mental Disorders Estimates of psychiatric co morbidity among clinical populations in substance abuse treatment settings range from 50 70% Estimates of substance use co morbidity among clinical populations in mental health treatment settings range from 20 50% Flynn and Brown, Co Occurring Disorders in Substance Abuse Treatment: Issues and Prospects, J Subst Abuse Treat January ; 34(1): Psychotic disorders Bipolar disorders Depressive disorders Anxiety disorders Obsessive compulsive and related disorders Sleep disorders Sexual dysfunctions Delirium Neurocognitive disorders Substance use disorders Substance intoxication Substance withdrawal DSM 5 Substance Induced Mental Disorders DSM 5 Substance Induced Mood Disorder (Prototype for other SIMDs) 3

4 Making the Diagnoses: Major Depressive Disorder vs. SIMD A significant period of abstinence may not be available for examination What are nature of sx (are they typical for the substance being used or for the co occurring disorder?) What is the duration of sx (are they typical for the substance being used or for the co occurring disorder?) What is the family hx? Longitudinal observation has more validity than cross sectional observation Not clear that a primary/secondary distinction has great meaning (both require primary tx. ) Nunes and Weiss, The ASAM Principles of Addiction Medicine 5 th Ed., 2014 Nunes EV, Levin FR. JAMA Apr 21;291(15): Nunes EV, Levin FR. JAMA Apr 21;291(15): Treatment of depression in patients with alcohol or other drug dependence: a meta analysis. Nunes EV, Levin FR. JAMA Apr 21;291(15): CONCLUSIONS: Antidepressant medication exerts a modest beneficial effect for patients with combined depressive and substanceuse disorders. It is not a stand alone treatment, and concurrent therapy directly targeting the addiction is also indicated. Why aren t Antidepressants more effective in addictions patients? Psychiatric outcomes: Antidepressants only beat placebo by 20% anyway in NON addicts Study patients also get addiction rx and maybe addiction rx is more anti dep, anti anx than we think (Schuckit 80% > 20% symptomatic after alcoholics enter tx) Positive effects on mood of 12 Step involvement Research included patients with SIMD? Addictions outcomes Meds take focus off sobriety for some patients? Just don t work for this 4

5 Bipolar Disorder vs. SIMD Treatment of Bipolar and Substance Use Disorders Pharmacologic treatment of bipolar disorder required for success Usual treatments for bipolar disorder Anticonvulsants may confer some protection from withdrawal Integrated Group Therapy targeted to patients with Bipolar Substance Abuse who are encouraged to see their dx as one disorder. IGT supported by randomized controlled trials. Nunes and Weiss, The ASAM Principles of Addiction Medicine 5 th Ed., 2014 Treatment of Psychotic and Substance Use Disorders Pharmacologic treatment of psychotic disorder required for success Unique role for clozapine in patients unresponsive to other antipsychotic medication and in reducing substance use and suicidal behavior Need for comprehensive services and case management Ziedonis, et. al, The ASAM Principles of Addiction Medicine 5 th Ed., 2014 DSM 5 Criteria for ADHD People with ADHD show a persistent pattern of inattention and/or hyperactivity impulsivity that interferes with functioning or development: 1) Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level. 2) Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person s developmental level. 3) In addition, the following conditions must be met: Several inattentive or hyperactive impulsive symptoms were present before age 12 years. Several symptoms are present in two or more setting, (e.g., at home, school or work; with friends or relatives; in other activities). There is clear evidence that the symptoms interfere with, or reduce the quality of social, school, or work functioning. Levin and Mariani, The ASAM Principles of Addiction Medicine 5 th Ed.,

6 DSM 5 PTSD Criterion A: stressor The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence Criterion B: intrusion symptoms The traumatic event is persistently re experienced Criterion C: avoidance Persistent effortful avoidance of distressing trauma related stimuli after the event Criterion D: negative alterations in cognitions and mood Criterion E: alterations in arousal and reactivity Criterion F: duration Persistence of symptoms (in Criteria B, C, D, and E) for more than one month Criterion G: functional significance Levin and Mariani, The ASAM Principles of Addiction Medicine 5 th Ed., 2014 Kendler, et. Arch Gen Psychiatry. 2000;57(10): Jacobson, et. al., JAMA, 2008 Nunes and Weiss, The ASAM Principles of Addiction Medicine 5 th Ed., 2014 Treatment of PTSD and Substance Use Disorders Jacobson, et. al., JAMA, 2008 Cognitive Behavior Therapy: Combines didactic element, exposure, relaxation training, and examination and evaluation of cognitions related to traumatic experiences Seeking Safety (Najavits,LM /seekingsafety.org ): Only model for PTSD and substance use disorder that meets standard criteria as an effective treatment (Chambless & Hollon, 1998). Pharmacotherapy: SSRIs, prazosin for nightmares and other sleep disturbances 6

7 DSM 5 General Criteria for Personality Disorder Personality Disorders The essential features of a personality disorder are Moderate or greater impairment in personality (self/interpersonal) functioning. One or more pathological personality traits. The impairments in personality functioning and the individual s personality trait expression are relatively inflexible and pervasive across a broad range of personal and social situations. The impairments in personality functioning and the individual s personality trait expression are relatively stable across time, with onsets that can be traced back to at least adolescence or early adulthood. The impairments in personality functioning and the individual s personality trait expression are not better explained by another mental disorder. The impairments in personality functioning and the individual s personality trait expression are not solely attributable to the physiological effects of a substance or another medical condition (e.g., severe head trauma). The impairments in personality functioning and the individual s personality trait expression are not better understood as normal for an individual s developmental stage or sociocultural environment. Borderline personality disorder: Dialectical behavioral therapy has been modified for the treatment of co occurring SUD (Linehan MM,et al. Drug Alcohol Depend 2002;67:13 26.) Antisocial personality disorder: Multisystemic Family Therapy for adolescents (Henggeler SW, J Consult Clin Psychol 1992;60: ); contingency management for adults (Messina N,. J Consult Clin Psychol 2003;71: ) Eating Disorders Lifetime co occurrence between SUD and eating disorders is 25% Anorexia nervosa: high rates of prescription and OTC misuse to control appetite Bulimia nervosa: high rates of SUD Binge eating disorder: evidence that it may be a behavioral addiction such as gambling disorder, highest rates of SUD (57% of men with BED also have SUD, 28% of women) among eating disorders Gambling Disorder (First DSM 5 Behavioral Addiction ) Soberay et. al., J Gambl St 2014 Mar;30(1):61 9. Pathological gambling, co occurring disorders, clinical presentation, and treatment outcomes at a university based counseling clinic. Study found elevated rates of depression, anxiety, and PTSD. Number of co occurring disorders present correlated with gambling severity. Nicotine/Cigarette Statistics Lifetime comorbidity between pathologic gambling and other psychiatric disorders. Odds ratios are given in last column. Kessler, et. al., Psychol Med., Persons with behavioral health disorders die up to 25 years earlier than the general population (NASMHPD, 2006) Persons with addictions and mental health problems: are nicotine dependent are a rate 2 3 times higher represent over 44 percent of U.S. tobacco market consume over 34 percent of all cigarettes smoked in the U.S. (Lasser et. al., 2000) 7

8 Cessation Concurrent with Mental Health or Addictions Treatment Lasser, Boyd, et. al., JAMA, Smoking cessation has no negative impact on psychiatric symptoms and smoking cessation may even lead to better mental health and overall functioning (Baker et al., 2006; Lawn & Pols, 2005; Morris et al., Unpublished data; Prochaska et al., 2008) Participation in smoking cessation efforts while engaged in other substance abuse treatment has been associated with a 25 percent greater likelihood of long term abstinence from alcohol and other drugs (Bobo et al., 1995; Burling et al., 2001; Hughes, 1996; Hughes et al., 2003; Hurt et al., 1993; Pletcher, 1993; Prochaska et al., 2004; Rustin, 1998; Saxon, 2003; Taylor et al., 2000) 44 Psychopharmacology of Mental Disorders with Co occurring Substance Use: Psychopharmacology of Substance Misuse in Patients with Co Occurring Disorders: Sparing use of benzodiazepines (which are not all created equal) and hypnotic medications. What s the evidence for use of quetiapine as a stand alone treatment for anxiety or insomnia? What s the risk/benefit? Does quetiapine have abuse potential? Remarkably few adverse interactions between drugs of abuse and prescribed drugs and abstinence not required for benefits of medication. Alcohol: Naltrexone has been found efficacious in pts. with alcohol dependence and other mental illness (depot preparation approved by FDA), disulfiram in well selected patients, acamprosate not tested yet in this population Nicotine: nicotine replacement and bupropion found efficacious in pts with nicotine dependence and other psychiatric disorders Opiates: Methadone maintenance effective and buprenorphine allows treatment of opiate dependent patients outside of methadone maintenance programs. Does naltrexone have a role with this population? Cognitive Behavioral Therapy Widely studied and found effective in variety of SUDs and other types of mental illness Also helpful in insomnia although not well tested in patients with COD Difficult to implement with fidelity to the approach use in (train, coach initial cases, monitor practice) CBT4CBT (promising computerized version of CBT with effectiveness and high patient/staff satisfaction, developed by Kathleen Carroll at Yale). Contingency Management in Patients with Co Occurring Disorders : Co occurring disorder patients more likely to obtain housing and employment when contingencies for abstinence in place (Milby et. al., 1996) Co occurring disorder patients more likely to obtain abstinence when incentive of self management of finances is offered (Ries, 1997) Attendance at dual dx group therapy was improved with contingency management for attendance (Helmus, et. al., 2003) 8

9 One Year of Abstinence is Predicted by: Double Trouble Recovery (DTR) Outcomes AA Involvement (OR=2.9) Not having pro drinking influences in one's network (OR=0.7) Having support for reducing consumption from people met in AA (versus no support; OR=3.4). In contrast, having support from non AA members was not a significant predictor of abstinence. Kaskutas, LA. Alcoholics Anonymous effectiveness: faith meets science. Journal of Addictive Disease, 28 (2): 2009, Members of 24 DTR groups (n=240) New York City, 1 year outcomes Drug/alcohol abstinence = 54% at baseline, increased to 72% at follow up. More attendance = better Medication adherence Better Medication adherence = less hospitalization Magura, Add Beh 2003, Psych Serv 2002 The Four Quadrant Framework for Co Occurring Disorders High severity Low severity Less severe mental disorder/ more severe substance abuse disorder Less severe mental disorder/ less severe substance abuse disorder More severe mental disorder/ more severe substance abuse disorder More severe mental disorder/ less severe substance abuse disorder High severity A four quadrant conceptual framework to guide systems integration and resource allocation in treating individuals with co occurring disorders (NASMHPD,NASADAD, 1998; NY State; Ries, 1993; SAMHSA Report to Congress, 2002) Current System Compartmentalizes Services 9

10 Sincere thanks for listening. Questions? 10